Pseudocyesis

Stephanie J. Campos, BSN, DNP, and Denise Link, PhD, FAAN

ABSTRACT
Pseudocyesis is a rare, but debilitating somatic disorder in which a woman presents
with outward signs of pregnancy, although she is not truly gravid. Commonly,
women of lower socioeconomic status, limited access to health care, and feeling under
significant stress to conceive are most at risk for this disorder. Although depression is
a frequent comorbidity alongside pseudocyesis, endocrinologic disorders have been
documented that mimic signs of polycystic ovary syndrome. This complex array of
concerns requires an understanding of similar differentials and treatment options.

Keywords: factitious pregnancy, delusion of pregnancy, pseudocyesis, somatic disorder

Ó 2016 Elsevier Inc. All rights reserved.

BACKGROUND PRESENTATION

W
hen a woman presents with presumptive
signs of pregnancy, pseudocyesis should
be included in the differential, despite its
rarity. According to the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5), pseudocyesis
(or pseudocyesis vera) is a derivative of the Greek
words, pseudçs, meaning “false,” and kyçsis, meaning
“pregnancy.”1,2 It is categorized under Somatic
Symptom and Related Disorders, for debilitating
mental health affliction leading to somatization.1,3
The medical literature has reported about 550
cases of pseudocyesis, with patients ranging in age
from 6 to 79 years.4 The majority of cases occur
within the 20- to 44-year age group. In the Western
world, the incidence is 1-6/22,000 births.5
The World Health Organization’s Mental Health
Action Plan emphasizes the importance of improving
women’s mental health, particularly when coupled
with significant stress, poverty, and domestic abuse.6
HealthyPeople 2020 estimates that 1 in 17 American
adults suffer from mental illness.7 Depression, which
often underlies pseudocyesis, accounts for 4.3% of all
diseases worldwide and is a leading cause of disability
both globally and in the United States.6,7 Major
depression involves a 40%-60% increased risk for
premature death, often as a result of additional poorly
managed illnesses.1,6
American Association of Nurse Practitioners (AANP) members may
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390 The Journal for Nurse Practitioners - JNP
Pseudocyesis commonly presents outside of the
mental health setting, with somatic manifestation of
pregnancy, triggered by severe distress related to
childbearing; for instance, recent miscarriage, infant
loss, or an extreme fear of pregnancy. Low socio-
economic status, limited education, a history of
infertility, relationship instability, and having an
abusive partner are common features of the female
with pseudocyesis.1,2,5,8 Eighty percent of these
patients are also married.5 The condition manifests
more frequently among younger women and within
cultures placing great value on childbearing and
motherhood.1
Considering these attributes, pseudocyesis is more
common in underdeveloped regions of the world,
but is certainly not isolated to those areas.1 For
instance, in Africa, its current incidence is relatively
common, occurring in 1 of every 160 of infertility
treatment patients, although historically the rate has
been recorded as 1 in every 25 births. In developed
countries, the incidence has decreased significantly
over recent decades.2,5 However, the African-
American subculture maintains a greater predilection
for pseudocyesis because of emphasis placed on
fertility and motherhood.1
Populations with convenient health care access
may be corrected early in the purported pregnancy
using substantive evidence (eg, laboratory analysis,
ultrasound) to the contrary.1,5 Unfortunately,
women with limited or no access may continue
their “pregnancy,” even through “labor.”1
Volume 12, Issue 6, June 2016
ASSESSMENT
In pseudocyesis, the patient history may reveal oligo-
or amenorrhea, changes in appetite, nausea, weight
gain, a sensation of fetal movement, breast enlarge-
ment or secretion, and even labor pain.1,2,5 Symptoms
may persist from a few weeks to beyond 9 months.5
At initial observation, the patient’s posture may
appear lordotic, and, during the physical assessment,
darkened pigmentation may be noted on the face,
abdomen, or around the areola. Abdominal disten-
sion is another common manifestation, but, upon
further evaluation, several characteristics are quite
different from true pregnancy. First, the umbilicus
in pregnancy is typically everted, whereas, in pseu-
docyesis, the umbilicus remains inverted. Second,
the abdomen is uniformly round, as opposed to
a womb-favoring fetal lie. Finally, in pseudocyesis,
abdominal palpation reveals a tight rubbery sensation,
and percussion elicits tympany.1,2,5,8
To facilitate diagnosis, recall that the presumptive
signs of pregnancy include abrupt-onset amenorrhea
(at least 10 days after menses were due to begin),
nausea and vomiting, breast tenderness and enlarge-
ment, urinary frequency, and fatigue (see Table).
Probable signs, present on objective evaluation,
include colostrum expression, and skin changes,
such as cholasma, linea nigra, and abdominal striae.
Not only will the abdomen appear enlarged, but
the uterus is enlarged as well, with palpable and
Table. Signs of Pregnancy
Presumptive & Probable Definitive
 Abrupt-onset amenorrhea  Fetal
 Nausea/vomiting visualization
 Breast tenderness/enlargement via ultrasound
 Urinary frequency  Fetal heart rate
 Fatigue auscultation via
 Colostrum production Doppler
 Chloasma/linea nigra/abdominal
striae
 Abdominal enlargement
 Chadwick’s sign
 Hegar’s sign
 Goodell’s sign
 Braxton-Hicks contractions
 Palpable fetal parts/movement
 Positive human chorionic
gonadotropin
Adapted from King et al.9, confirmed by Cunningham et al.10
www.npjournal.org
ballottable fetal parts (particularly apparent in the
third trimester).9 Other presumptive signs include
Chadwick’s sign (increased vascularity of ectocervix,
which appears dark bluish-red), Hegar’s sign (soft-
ening of the isthmus between cervix and uterus),
Goodell’s sign (cervical edema), palpable Braxton-
Hicks contractions, a positive urine pregnancy test,
and palpable fetal movement.9,10 Serum human
chorionic gonadotropin (hCG) is helpful in diagnosis
as false-positive results are rare, but may occur in
women who work extensively with animals, or
have renal failure, a physiologic pituitary hCG, or
an hCG-producing tumor (such gastrointestinal,
ovary, bladder, or lung).10 The only definitive
signs of pregnancy to rule out pseudocyesis include
fetal visualization via ultrasound or fetal heart rate
auscultation by Doppler.9,10 Around the sixth week
of gestation, an embryo should be visualized via
ultrasonography,10 but, ultimately, sound clinical
judgment must be employed when deciding on
how long to continue testing for true pregnancy.
DIFFERENTIALS
An important differential diagnosis from pseudocyesis
is delusion of pregnancy, which lacks physical signs
of pregnancy. The DSM-5 categorizes delusion of
pregnancy under the schizophrenic spectrum and
psychotic disorders, thus necessitating a very different
treatment from that of pseudocyesis.1,2 Two other
differentials include factitious (or deceptive) pregnancy and
erroneous pseudocyesis. A woman who consciously
behaves as if pregnant for some gain (eg, sympathy,
attention) is said to be experiencing a factitious
pregnancy. On the other hand, if a presumptive or
probable sign of pregnancy occurs (eg, amenorrhea
or galactorrhea), causing a female to erroneously
believe herself pregnant, it is considered an erroneous
pseudocyesis.1 Pathologic conditions precipitating
erroneous pseudocyesis may include tumors,
hydatidiform mole, ovarian cysts, uterine fibroids,
ascites, urinary retention, and so forth, all of which
must be ruled out in the absence of true pregnancy.8,11
PATHOPHYSIOLOGY
The diagnosis of pseudocyesis presents an interesting
dichotomy: psychological insults from a person’s
behavioral and emotional state have been known to
The Journal for Nurse Practitioners - JNP 391
confound or even cause physical alterations,
including infection, cancer, diabetes, and cardiovas-
cular disease.12 Conversely, physical illness (both
acute and chronic) is known to deteriorate mental
well-being.12 Is societal pressure or a traumatic event
the underlying precursor to pseudocyesis? Or is the
physical dysfunction of infertility or abnormal
menstruation undermining a healthy mental state?
As cases of true pseudocyesis in the literature are
rare, there are no evaluation, testing, or treatment
guidelines, and published data are widely variable.
With individual studies and such small sample sizes
(eg, n ¼ 1), the endocrinology and pathophysiology
of pseudocyesis has traditionally been regarded as
inconclusive.1,4 However, in a literature review by
Tarin et al.,1 the research team pooled reports from
10 female patients, observing several common
endocrinologic and pathologic traits (see Figure).
Deficits in dopamine are often observed in
pseudocyesis; so it is not surprising that depression,
anxiety, or emotional distress are hallmarks of patients
suffering from the condition. It has long been supposed
that the catecholaminergic pathway, which regulates
anterior pituitary hormone secretion, is dysfunctional in
Figure. Suspected pseudocyesis pathophysiology
FSH ¼ follicle-stimulating hormone; GnRH ¼ gonadotropin-releasing hormone; LH ¼ luteinizing hormone.
See Tarin et al.1 King et al.,9 and Sherwood.16
392 The Journal for Nurse Practitioners - JNP
women presenting with pseudocyesis.1 Because
dopamine inhibits the gonadotropin-releasing hormone,
leutinizing hormone pulsatility, and prolactin levels, a
deficiency can cause elevations in the latter hormones,
including an elevated leutinizing hormone/follicular-
stimulating hormone ratio.1 Oligo- or amenorrhea,
galactorrhea, and hyperprolactinemia may result,
accounting for reported signs in pseudocyesis.1 When
catecholaminergic activity is reduced, so may be the
steroid feedback, allowing a rise in gonadotropin-
releasing hormone and subsequent leutinizing hormone
production, particularly when compared with follicular-
stimulating hormone. This is particularly seen in women
with polycystic ovary syndrome.1 Researchers have
noted extensive endocrinologic similarities between
pseudocyesis and polycystic ovary syndrome, which is a
common condition implicated in oligo/amenorrhea and
infertility.1,13
In regard to abdominal enlargement, “fetal
movement,” and “labor pain,” research suggests
increased sympathetic nervous system activity is
responsible for perceived symptoms.1 Chronic
diaphragmatic contraction, increased abdominal
adipose tissue, constipation, and lordotic posturing
Volume 12, Issue 6, June 2016
may contribute to why the abdominal distention
is visible.1 Some researchers believe pseudocyetic
women initially experience abdomino-phrenic
dyssynergia, which is prolonged diaphragmatic
contraction accompanied by abnormal contraction
and relaxation of the abdominal muscle.1 This
phenomenon results from chronic gas and bloating
leading to abdominal distension.1 Subsequently,
abdominal spasms occur (such as those inferred
in pseudo-labor), called hysterical abdominal proptosis.1
Curiously, in some cases, when a pseudocyetic
patient is sedated with anesthesia or accepts the
truth of her nonpregnant state, the abdominal
distention spontaneously resolves, with or without
passing flatus.1,14 Yet, in some case studies, once
the patient returns to consciousness, the distension
returns to its pre-anesthesia girth.14
Kamal et al.8 also believe the occurrence of
pseudocyesis near menopause occurs secondary to
normal aging physiology, with irregular menstruation
cycles and increasing fatty deposits in the abdomen
and breast tissue.
As far as the psychophysical complexities, anxiety
and depression can lower pain threshold and increase
pain intensity,12 and this may also explain the
“pregnancy” pain or “labor” pain. Obesity, often
observable in abdominal distension, is tightly linked
with depression. Feelings of inadequacy vis-à-vis
appearance only complicate pressures for pregnancy
or feelings of turmoil from an unexpected loss,
from which depression spirals downward. Depression
can directly lead to obesity in terms of sedentary
behavior and unhealthy diet and, as an added insult,
many psychiatric medications cause weight gain
and amenorrhea, leading some patients to believe
themselves pregnant.12,15
TREATMENT
Recurrent cases of pseudocyesis have been reported,
giving credence to an underlying psychiatric
disorder.5 When a mood disorder is the root of
pseudocyesis, negative pregnancy markers are likely
to antagonize the woman’s psychological imbalance.4
Unfortunately, somatic diseases, such as pseudocyesis,
often manifest in apathy to seek treatment for mental
health concerns.12 Instead, these patients may present
frequently for inconsequential physical ailments,
www.npjournal.org
never discussing unrequited emotional needs, as
the topic is rarely breached by physical health
providers, nor is it an expected part of conversation
by patients in settings outside of the psychiatrist’s
office.12 Regardless, referral for psychiatric evaluation
is imperative, as combined psychodynamic and
psychotherapy, and possibly even pharmacotherapy,
are preferred treatments.2,4,12
Suggestions for pharmacotherapy are limited
in the literature. Dopamine has successfully treated
pseudocyesis in animals, canines in particular, by
suppressing prolactin levels, but the extent of
prolactin’s role in human pseudocyesis is not as
well understood.14
IMPLICATIONS
Practitioners presented with this situation in the
realm of primary care must be cognizant, recognizing
signs, such as those discussed, that necessitate
psychiatric follow-up. The practitioner is in a
unique position to influence the next steps a
woman with pseudocyesis chooses to take, as her
first expert contact. The prudent practitioner
understands, however, that he or she is likely to
trigger increased depression with news of her
nongravid state, but also has an opportunity to
foster a trusting relationship during this difficult
time. With a customized primary care and
mental health collaborative plan, the patient may
be more likely to take her first steps toward
recovery.7,12
References
1. Tarin JJ, Hermenegildo C, García-Pérez MA, Cano A. Endocrinology and
physiology of pseudocyesis. Reprod Biol Endocrinol. 2013;11(39):1-12.
2. Yadav T, Balhara YPS, Kataria DK. Pseudocyesis versus delusion of
pregnancy: differential diagnoses to be kept in mind. Ind J Psychol Med.
2012;34(1):82-84.
3. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders. 5th ed. Arlington, Va: APA; 2013.
4. Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD,
Cunningham FG. Williams Gynecology. 2nd ed. New York: McGraw-Hill
Medical; 2012.
5. Ibekwe PC, Achor JU. Psychosocial and cultural aspects of pseudocyesis. Ind
J Psychiatry. 2008;50(2):112-116.
6. World Health Organization. Mental Health Action Plan 2013-2020. http://www
.who.int/mental_health/publications/action_plan/en/. Accessed April 21, 2015.
7. HealthyPeople.gov. Mental health and mental disorders. 2013. http://www
.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental
-disorders/. Accessed April 11, 2015.
8. Kamal A, Rahman W, Laila L, Hakim N. Case report on pseudocyesis. J Armed
Forces Med Coll. Bangladesh. 2012;8(1):56-68.
9. King TL, Brucker MC, Kriebs JM, Fahey JO, Gegor CL, Varney H. Varney’s
Midwifery. 5th ed. Burlington, Mass: Jones & Bartlett Learning; 2015.
10. Cunningham FG, Leveno KJ, Bloom SL, et al. Williams Obstetrics. 24th ed.
New York: McGraw-Hill Medical; 2014.
The Journal for Nurse Practitioners - JNP 393
11. Yeh Y-W, Kuo S-C, Chen C-Y. Urinary tract infection complicated by urine AZ. In compliance with national ethical guidelines, the authors
retention presenting as pseudocyesis in a schizophrenic patient. Gen Hosp
Psychiatry. 2012;34(1):101.e9-101.e10. report no relationships with business or industry that would pose a
12. Dudek D, Soba nski JA. Mental disorders in somatic diseases: psychopathology
and treatment. Polskie Archiwum Medycyny Wewnȩtrznej. 2012;122(12):
conflict of interest.
624-629.
13. The Practice Committee of the American Society for Reproductive Medicine.
Diagnostic evaluation of the infertile female: a committee opinion. Fertil 1555-4155/16/$ see front matter
Steril. 2012;98(2):302-307. © 2016 Elsevier Inc. All rights reserved.
14. Del Pizzo J, Posey-Bahar L, Jimenez R. Pseudocyesis in a teenager with http://dx.doi.org/10.1016/j.nurpra.2016.03.009
bipolar disorder. Clin Pediatr. 2011;50(2):169-171.
15. Seeman MV. Antipsychotic-induced amenorrhea. J Ment Health.
2011;20(5):484-491. The activity is approved for 0.7 contact hour(s) of
16. Sherwood L. Human Physiology: From Cells to Systems. 7th ed. Belmont,
Calif: Brooks/Cole, Cengage Learning; 2010. continuing education by the American Association of
Nurse Practitioners (AANP). Program ID 16052192.
This activity was planned in accordance with AANP
Stephanie J. Campos, BSN, DNP. She may be contacted at
CE Standards and Policies. AANP members may
stephanie.campos@yahoo.com. Denise Link, PhD,
receive credit by completing the online posttest and
WHNP, FAAN is a Clinical Professor at Arizona State
evaluation at cecenter.aanp.org/program?area¼JNP.
University College of Nursing and Health Innovation, Phoenix,

394 The Journal for Nurse Practitioners - JNP Volume 12, Issue 6, June 2016